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CLAIM NOTICE - THIS IS NOT A BILL

JUNE 30, 2011

MEMBER INFORMATION
Member: ID Number: Group information: RODNEY S CAUDILL 106821876001 LTV363

PROVIDER SUMMARY
Provider: VIAU MICHAEL R MD

Total Provider's Charge: $390.00 For Claim Number(s): 11172976320 Covered benefit amount we paid you: Covered benefit amount we paid: If not already paid, the provider may bill you:

$0.00 $0.00 $390.00

Provider:

BUEHRER

PAUL

MD

Total Provider's Charge: $206.00 For Claim Number(s): 11180986326 Covered benefit amount we paid you: Covered benefit amount we paid: If not already paid, the provider may bill you:

$0.00 $0.00 $206.00

PROVIDER SUMMARY continued on next page

Camp Hill, PA 17089-0089

#BWNDBQH #OCS8931781236365# RODNEY S CAUDILL 953 WOODBINE ST WILLARD OH 44890 NN001542

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PROVIDER SUMMARY continued

Provider: MCGARVEY KEVIN P DPM

Total Provider's Charge: $290.00 For Claim Number(s): 11181492356 Covered benefit amount we paid you: Covered benefit amount we paid: If not already paid, the provider may bill you:

$0.00 $87.55 $0.27

Provider:

ROSSO

JAMES

MD

Total Provider's Charge: $27.00 For Claim Number(s): 11181409284 Covered benefit amount we paid you: Covered benefit amount we paid: If not already paid, the provider may bill you:

$0.00 $0.00 $27.00

PATIENT BENEFIT SUMMARY

Patient: RODNEY S CAUDILL Benefit Period: 01/01/11 - 12/31/11 You have satisfied $13.94 of your $75.00 individual deductible. Please refer to your benefit booklet or agreement for further information. Amount(s) shown may include totals from claims which are still being processed and for which you have not been notified.

PROGRAM BENEFIT SUMMARY

Benefit Period: 01/01/11 - 12/31/11

You have satisfied $150.00 of your $150.00 program deductible. Please refer to your benefit booklet or agreement for further information. Amount(s) shown may include totals from claims which are still being processed and for which you have not been notified.

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JUNE 30, 2011

Member Service Member Service:

8:00 am - 5:00 pm Monday - Friday

1-800-811-0391

If your claim has been denied in whole or in part, you have 180 days from receipt of this notice to file a written appeal to the following address: Member Grievance and Appeals, P.O. Box 535095 Pittsburgh, PA 15253-5095, Attention: Review Committee Your appeal process has 1 level(s) of appeal. For a description of the appeal process, please refer to the Administration section of your Benefit Booklet or call our Member Service Department at the number listed above. You may appoint a representative to act on your behalf in pursuing an appeal. You must provide us with the name and address of your authorized representative and a description of the services being appealed in a written consent form signed by you. If you consent to the filing of an appeal by your authorized representative, you cannot file a separate appeal. For a copy of the authorized representative consent form, please call our Member Service Department at the number listed above. You have the right under section 502(a) of the Employee Retirement Income Security Act of 1974 to file a civil action if an adverse benefit determination is made following completion of the internal appeal process. (TTY services via 1-800-452-8086 for the hearing and speech impaired.)

"For online member service, view or update other insurance information, check eligibility or claims status, logon to our website at: www.highmark.com"

Adverse Benefit Determination Information

If you need a copy of the member's Benefit Booklet, contact your employer or other plan administrator.

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CLAIM DETAIL
Patient: RODNEY S CAUDILL Provider: VIAU Service Date 06/03/11 MICHAEL Service Description Service Code (Number of Services) OFFICE/OUTPATIENT VISIT 99203 ARM CAST 29075 (1) 226.00 (1) 226.00 L5015A 226.00 R Provider's Charge 164.00 ID Number: 106821876001 MD Our Allowance Covered Benefit Amount Amount Not Paid 164.00 Remarks (see last section) L5015A Amount You Owe Provider 164.00 Claim Number: 11172976320

06/03/11

Totals

390.00

390.00

390.00

CLAIM DETAIL
Patient: RODNEY S CAUDILL Provider: BUEHRER Service Date PAUL Service Description Service Code (Number of Services) C Provider's Charge ID Number: 106821876001 MD Our Allowance Covered Benefit Amount Amount Not Paid Remarks (see last section) Amount You Owe Provider Claim Number: 11180986326

CLAIM DETAIL continued on next page

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CLAIM DETAIL continued

Patient: RODNEY S CAUDILL Provider: BUEHRER Service Date 06/20/11 PAUL Service Description Service Code (Number of Services) ADVANCED IMAGING - CT 73200 (1) C Provider's Charge 206.00 ID Number: 106821876001 MD Our Allowance Covered Benefit Amount Amount Not Paid 206.00 Remarks (see last section) L5015A Amount You Owe Provider 206.00 Claim Number: 11180986326

Totals

206.00

206.00

206.00

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CLAIM DETAIL
Patient: RODNEY S CAUDILL Provider: MCGARVEY Service Date 05/25/11 KEVIN P Provider's Charge 70.00 (1) 70.00 R5188 0.00 ID Number: 106821876001 DPM Our Allowance Covered Benefit Amount Amount Not Paid Remarks (see last section) Amount You Owe Provider 0.00 Claim Number: 11181492356

Service Description Service Code (Number of Services) OFFICE/OUTPATIENT VISIT 99213 100% OF BENEFIT

05/25/11

SKIN BIOPSY 11100 LIGAMENT/GANGLION INJEC 20550 THERAPEUTIC INJECTION J1020 80% OF BENEFIT

125.00 (1) 80.00 (1) 15.00 (1)

64.40

64.40

60.60

J0022

0.00

05/25/11

22.05

22.05

57.95

J0022

0.00

05/25/11

0.00 1.37 1.10 .27 13.63 Coinsurance 20% J0022 0.27

Totals

0.27

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CLAIM DETAIL
Patient: DYLAN S CAUDILL Provider: ROSSO Service Date 06/24/11 JAMES Service Description Service Code (Number of Services) OFFICE/OUTPATIENT VISIT 99211 (1) E Provider's Charge 27.00 ID Number: 106821876001 MD Our Allowance Covered Benefit Amount Amount Not Paid 27.00 Remarks (see last section) U5002A Amount You Owe Provider 27.00 Claim Number: 11181409284

Totals

27.00

27.00

27.00

REMARKS
J0022 L5015A This is the difference between the provider's charge and our allowance. We do not pay for services paid or payable by an automobile insurance plan. Please submit these bills to the automobile insurance company. R5188 - No allowance is being made for this service due to an agreement with the provider. Based on this agreement, the member is not responsible for this charge. U5002A - The patient's coverage does not provide for this Routine Preventative Health Care service. Therefore, no payment can be made. All services were considered according to our guidelines and similar services may have been combined. Therefore, the services shown on the Claim Detail may not match what was originally submitted on your claim. We provide administrative claims payment services only and do not assume any financial risk or obligation regarding claims.

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If you suspect fraud or abuse involving your health insurance, please call the toll-free fraud or abuse hotline at 1-800-438-2478.

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